Last year it was reported that a 9-year-old boy had died at school
from sleep apnoea and Pickwickian syndrome. He weighed between 105 and
120 kg, and despite the overseeing medical doctor insisting that he be
admitted for further investigations and treatment, his parents refused.
He had been falling asleep in the classroom on a regular basis for 2
months before his tragic death.

Obesity rates among children and adolescents have reached epidemic
proportions in both industrialised and developing countries, with an
estimated 1 out of every 5 youngsters suffering from obesity at a BMI
above 30. (1) Childhood obesity is a strong predictor of adult obesity,
and very difficult to treat once established. (2) Childhood obesity also
predicts an increased risk of death, primarily due to an increased
likelihood of cardiorespiratory death. (3) The rise in the
cardiovascular death rate is explained by the increased risk factor
profile from high rates of hypertension, dyslipidaemia, type (2)
diabetes and sleep apnoea. (4) Longitudinal studies looking at various
risk factors, including carotid intima-media thickness, have indicated
that adults who became obese but had a normal BMI in childhood had a
more adverse risk profile. Adults who were obese as children and then
normalised their BMI had a risk profile similar to patients who had
never been obese during childhood. (5)

Given the above, active intervention in childhood obesity is likely
to have a number of benefits. However, we face the difficult scientific
problem that circulating levels of biological mediators of appetite
which encourage weight regain after induced weight loss do not revert to
the levels recorded before weight loss. (6) Long-term strategies and
research to counteract this change are needed to prevent obesity
relapse, and so far we have failed in this area. Various other factors
have contributed to our lack of success in containing childhood obesity,
including living in neighbourhoods with a high level of poverty, (7)
sleep deprivation during childhood, (8) consumption of sugary drinks,
frequent ingestion of fast foods, (9) and lack of physical activity. (9)

Less well-recognised medical conditions associated with childhood
obesity include non-alcoholic fatty liver, gastro-oesophageal reflux,
slipped capital femoral epiphyses, pseudo-tumour cerebri, and a high
risk of certain cancers. At the onset these medical conditions may be
less destructive than the stigma of obesity and the psychological trauma
experienced by bullying and stigmatisation.

Morbid obesity seems virtually impossible to treat with lifestyle
intervention alone. A 2-year trial of obesity treatment in primary care
practice indicated that quarterly visits with brief counselling had no
impact on weight loss. Enhanced weight loss counselling by lifestyle
experts helped around one-third of patients to achieve a 5% sustained
weight loss over 2 years. (10) A recent meta-analysis supported the view
that accredited bariatric surgery in an established centre of excellence
staffed by committed and adequately trained medical

professionals is a good solution in adolescents. (10) Patients keep
their weight off in the long term and have a high rate of resolution of
their co-morbidities. (11) The Roux-en-Y gastric bypass involves
minimally invasive laparoscopic surgery, and is the procedure most
frequently performed worldwide. Mortality (< 1 %) and morbidity (~
4-8 %) rates are low in expert hands. (11)

Recently Robert C Whitaker from the Department of Health in
Philadelphia passed the following thought-provoking comment: 'The
childhood obesity epidemic is just one symptom of our way of living.
Reversing the epidemic may require that we apply a new approach to
improving child and adult health in the 21st century. One approach would
be to make societal changes to enhance human well being rather than to
try and prevent a particular symptom such as obesity.'

Blaming, shaming and punishing the obese will not solve the
problem--it is simply shooting the messenger. If parents fail to
recognise that their child is obese, they are unlikely to recognise that
interventions targeting obesity are relevant to the family.